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Rehabilitation of Medial Ligament Injuries

Clinical Concepts Medial ligament injuries are among the most frequently treated problems of the knee joint. Whereas isolated superficial medial collateral ligament (SMCL) ruptures are common, concomitant damage to the anterior cruciate ligament (ACL) occurs in many cases, especially in younger active patients. The majority of isolated acute injuries that involve damage to the SMCL alone, or to the SMCL and posteromedial capsule (PMC), do not…

Medial and Posteromedial Ligament Injuries: Diagnosis, Operative Techniques, and Clinical Outcomes

Indications Medial ligament injuries are among the most frequently treated problems of the knee joint, with the majority not requiring operative intervention. Whereas isolated superficial medial collateral ligament (SMCL) ruptures are common, concomitant damage to the anterior cruciate ligament (ACL) also occurs in many cases, especially in young and active patients. Overall, there are four types of SMCL injury patterns: (1) SMCL tears that also almost…

Rehabilitation of Posterior Cruciate Ligament and Posterolateral Reconstructive Procedures

Clinical Concepts Critical Points Clinical Concepts Protocol for posterior cruciate ligament reconstruction for procedures with high-strength two-strand graft (quadriceps tendon-bone, bone-patellar tendon-bone). Progress patient on athletic and occupational goals, condition of the articular surfaces and menisci, return muscle function, postoperative healing, remodeling. Supervised rehabilitation program supplemented with home exercises performed daily. Monitor joint swelling, pain, gait pattern, knee motion, patellar mobility, muscle strength, and flexibility continually…

Posterolateral Ligament Injuries: Diagnosis, Operative Techniques, and Clinical Outcomes

Indications Critical Points Indications 6- to 10-mm increased lateral tibiofemoral joint opening 20 degrees of flexion. ≥15 degrees increased external tibial rotation 30 degrees, 90 degrees of flexion. ± Varus recurvatum, standing and supine. ± Hyperextension gait abnormality. Double or triple varus knee, after osteotomy. Acute injuries, bony avulsions amendable to internal fixation. The primary soft tissue–stabilizing structures of the posterolateral (PL) aspect of the knee…

Posterior Cruciate Ligament Injuries: Diagnosis, Operative Techniques, and Clinical Outcomes

Indications Critical Points Indications Mechanism of injury, low versus high velocity. Complete PCL rupture usually associated with other ligament injuries. Isolated PCL rupture represents serious injury, chance of functional deterioration, arthritis over time. Indications for chronic isolated complete PCL rupture: pain and instability with athletics or other activities, swelling, ≥10 mm of increased posterior tibial translation (90 degrees of flexion). Results of PCL reconstruction in chronic knees…

Function of the Posterior Cruciate Ligament and Posterolateral Ligament Structures

Introduction This chapter provides a summary of the important biomechanic principles gained from our publications and other investigations regarding the posterior cruciate ligament (PCL) and posterolateral structures (PLSs). The primary PLSs of the knee joint are the fibular collateral ligament (FCL) and popliteus muscle-tendon-ligament unit (PMTL), including the popliteofibular ligament (PFL) and posterolateral capsule (PLC). Additional PLSs that may be injured and require repair are iliotibial…

Decreasing the Risk of Anterior Cruciate Ligament Injuries in Female Athletes

Scientific Rationale and Supporting Investigations for Sportsmetrics Neuromuscular Retraining Program This chapter presents the scientific rationale, supporting data, and specific strategies for the implementation of Sportsmetrics, a neuromuscular knee ligament injury prevention training program. Since Sportsmetrics was first introduced to the medical community by the senior author (F.R.N.) and associates in 1996, at least 50 other so-called anterior cruciate ligament (ACL) injury prevention programs have followed…

Risk Factors for Anterior Cruciate Ligament Injuries in the Female Athlete

Video Content Video 11-4 Sportsmetrics Neuromuscular Conditioning Programs to Prevent ACL Injuries in Female Athletes Introduction It is well recognized that female athletes and military recruits have a higher incidence of noncontact anterior cruciate ligament (ACL) injuries than males participating in the same activity. A study done at our institution and published in 1994 was the first to recognize this gender disparity in female soccer players,…

Neuromuscular Training After Anterior Cruciate Ligament Reconstruction

Introduction Rehabilitation after anterior cruciate ligament (ACL) injury and surgery has evolved in the past 2 decades from programs that recommended 6 to 8 weeks of immobilization, restricted range of motion (ROM) and strengthening exercises, and a delay in return to sports activities for 9 to 12 months postoperatively. Current therapeutic programs implement immediate knee motion, weight bearing, and functional exercises, as well as proprioception and…

Rehabilitation of Primary and Revision Anterior Cruciate Ligament Reconstruction

Clinical Concepts Critical Points Clinical Concepts Protocols are evaluation based: Progression is based on continual evaluation using the principles of anatomy, physiology, biomechanics, and surgery. Goals Regain normal knee stability Control joint pain, swelling, and hemarthrosis Regain normal range of knee motion Restore normal gait pattern Recover normal lower limb muscle strength Regain normal proprioception, balance, coordination, and neuromuscular control Achieve optimal functional outcome based on…

Scientific Basis of Rehabilitation After Anterior Cruciate Ligament Autogenous Reconstruction

Introduction Considerable advances have been made in the treatment of complete anterior cruciate ligament (ACL) ruptures and reconstruction methods. These include the appropriate selection of patient candidates and criteria for goals that should be achieved before surgery, such as resolving limitations of knee motion, muscle atrophy, gait abnormalities, pain, and joint effusion. Appropriate graft selection, harvest, implantation, tensioning, and fixation are all paramount to achieving a…

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Introduction Mid-substance anterior cruciate ligament (ACL) injuries in the skeletally immature athlete are being recognized with increasing frequency. ACL injury has been reported in 10% to 65% of pediatric knee injuries with acute hemarthroses. This increased incidence is largely attributed to changes in the activity patterns of young athletes. Participation in sports is on the rise, with young athletes training year-round and specializing at earlier ages.…

Anterior Cruciate Ligament Revision Reconstruction: Graft Options and Clinical Outcomes

Indications Critical Points Indications Determine factors that caused the prior ACL reconstruction to fail Address all pathologies before surgery: lower limb malalignment, muscle atrophy, limitation knee motion, gait abnormalities, misplaced tunnels. Goals, outcome of surgery depend on preexisting joint damage, associated procedures required. Knees with misplaced tunnels with intact menisci and articular cartilage: most ideal outcome expected. Knees with prior meniscectomy, articular cartilage damage, other ligament…

Anterior Cruciate Ligament Primary Reconstruction: Diagnosis, Operative Techniques, and Clinical Outcomes

Indications Critical Points Indications Complete ACL rupture: >5 mm of increased anterior tibial translation, positive pivot shift test. Profile patient for desired future activity level. High-risk activities (pivoting, cutting, twisting, and turning): reconstruct. Acute ACL rupture and concomitant displaced bucket-handle meniscus tear: surgery within 2 to 3 weeks to repair meniscus, usually concurrent ACL reconstruction. Low-risk activities, willing to avoid strenuous activities that place the knee at…

Human Movement and Anterior Cruciate Ligament Function: Anterior Cruciate Ligament Injury and Gait Mechanics

Introduction Critical Points Introduction The purpose of this chapter is: To develop some fundamental gait analysis principles. To illustrate the application of gait analysis to the issues related to the evaluation and treatment of ACL injury. To describe the cause and implications of a change in muscle-generated moments after ACL injury. To describe kinematic changes at the knee during walking and the association of kinematics changes…

Biology of Anterior Cruciate Ligament Graft Healing

Introduction Traumatic rupture of the anterior cruciate ligament (ACL) can be a common source of knee instability and dysfunction in athletes. Reconstruction of a torn ACL, to restore function and limit injury to the menisci, has become a common orthopedic procedure. Despite advances in surgical techniques and the ability to implant an isometric graft that restores knee stability, ACL reconstruction is not always a universally efficacious…

Knee Ligament Function and Failure

Ligament Fiber Length-Tension Properties Critical Points Ligament Fiber Length-Tension Properties Numerous publications demonstrate how ligament fiber function depends on the initial length and attachment site and the specific joint position of both flexion-extension and tibial rotation. These concepts form the basis for the placement of knee ligament grafts, provide insight into single- and double-bundle cruciate reconstructions, and form the basis for the tensioning rules regarding knee…

Scientific Basis for Examination and Classification of Knee Ligament Injuries

Classification System for Knee Ligament Injuries Critical Points Classification System for Knee Ligament Injuries Purpose of a Classification System Make accurate distinctions between separate pathologic conditions in laboratory and clinical studies. Provide a common descriptive tool for investigators who wish to present cases and describe the outcome of treatment programs. Our Classification System Based on Seven Concepts 1. The final diagnosis of knee ligament injuries is…

Lateral and Posterior Knee Anatomy

Introduction The posterior and lateral anatomy of the knee joint presents a challenge to even the most experienced knee surgeon. Knowledge of the bony topography will result in a greater number of anatomic ligament reconstructions ( Fig. 2-1 ). A lack of familiarity leads to hesitancy when performing approaches in these areas of the knee. The inherent anatomic complexity of this region is further complicated by…

Medial and Anterior Knee Anatomy

Medial Anatomy of the Knee The medial anatomy of the knee consists of several layers of structures that work together to provide stability and function. Authors have used a variety of anatomic terms and descriptions that, unfortunately, have created ambiguity and confusion regarding this area of the knee. Two anatomic classifications or descriptions have been proposed to aid in the understanding of the relationships of the…